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STATE OF CALIFORN111 WATER RESOURCES CONTROLBOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r�- COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT © 5 CHANGE OF INFORMATION ❑ 7 R ENTLYCLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 160 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION P L-VE (z ADDRESS NEAREST CROSS STREET ✓Sab WW]X 0 PWNAF HIP 0 STATE AGENCY C' !J 0 CaroMTION 0 LOGAAGENCY 0 RGERkAGENCY O Nomook ❑ COUNT AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA 53-7 TYPE OF BUSINESS'. ❑ Y DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p RESERVATION or N of TANK'N �} ❑ 1 GAS STATION [:B/3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE Al WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL.AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicate 0 PARTNERSHIP 0 STATE AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVI ADDRIII SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ Ill. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYI! JURISDICTION N AGENCYII FACILITY ID N N of TANKS at SITE 14� 01I171 101010101 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LATION CODE CENSUS TRACT N SUPERVISOR-OISTRICT CODE BUSINESS PLAN FILED DATE FILED �-f YES ❑ NO ❑ —ZZ'-6 CK N / PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOWANIED BY AT LEAS lt)OR BORE TANK PERYR FORM `B'APPLICATION(S),BLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) -